Healthcare Provider Details

I. General information

NPI: 1891204525
Provider Name (Legal Business Name): JEIMY P GLAZE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 CORAL RIDGE DR
CORAL SPRINGS FL
33076-3378
US

IV. Provider business mailing address

5850 CORAL RIDGE DR STE 106
CORAL SPRINGS FL
33076-3379
US

V. Phone/Fax

Practice location:
  • Phone: 954-714-8200
  • Fax:
Mailing address:
  • Phone: 954-714-8200
  • Fax: 954-840-2626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPAT9110698
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAT9110698
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9110698
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: